Texas is a mess

[amyl]

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Anyone know anything about essential anesthesia or what’s going on in Houston? The Texas AGs statement placing all the responsibility for ratios on the anesthesiologist leads to this extended care team bs. Russian roulette with patient care and your license.
I heard gossip that this group in Irving is run by a pulmonologist. The sellout anesthesiologists that take these jobs really piss me off.

 

[MirrorTodd]

Anyone know anything about essential anesthesia or what’s going on in Houston? The Texas AGs statement placing all the responsibility for ratios on the anesthesiologist leads to this extended care team bs. Russian roulette with patient care and your license.
I heard gossip that this group in Irving is run by a pulmonologist. The sellout anesthesiologists that take these jobs really piss me off.

Currently contracted with essential on a prn basis here in San Antonio. They aren't bad to work for. Pay was low initially, primarily due to my amateur status in negotiations. Currently earning $300/hr with an 8hr guarantee and $325 for overtime and then there's call stipends. They've always paid me on time and haven't ever given me any issues with psycho demands. It's possible he moved but the founder lives in Southlake as far as I know. I'd say their salaried positions need to come up higher cause the hospitals that they currently are contracted for a run somewhat poorly so you're gonna be working more than a few hours.

 

[amyl]

so medical direction in San Antonio or ? Extended care team? That’s a pretty low rate - just for your information - I don’t know anyone who works for less than 350 for day time hours.

 

[aneftp]

so medical direction in San Antonio or ? Extended care team? That’s a pretty low rate - just for your information - I don’t know anyone who works for less than 350 for day time hours.

Me me. I work for $300/325 some days. Usually it’s pretty close to my house and I’m done at 1pm so I get paid all 8 hrs anyways due to guarantee hours.

Sam Antonio pays $400/hr by the way and up if cardiac. Unless you are some person who doesn’t negotiate well like my friend who took $325/hr. But than again he took $340/hr in Indiana and I’m like wtf dude. I told u they pay $400/425/hr

 

[AKMD_1984]

Anyone know anything about essential anesthesia or what’s going on in Houston? The Texas AGs statement placing all the responsibility for ratios on the anesthesiologist leads to this extended care team bs. Russian roulette with patient care and your license.
I heard gossip that this group in Irving is run by a pulmonologist. The sellout anesthesiologists that take these jobs really piss me off.

Yea...

Here's some interesting facts:

Dr. Link is a pulmonologist.
Dr. Bolnick does addiction medicine. He's an anesthesiologist, but I do not believe he does OR anesthesia regularly (or at all).

Those are the front figures but all operations, scheduling, management is CRNA that are in partnership with them. They do not advertise this.

So Essential anesthesia, like a few other management companies that purposely and vaguely pretend to be "X Anesthesia" or "X partners" are all CRNA driven. They are using MDs to legitimize the operation and bill under them and negotiate contracts with hospitals. Most MDs are happy on a salary.

Salary is not always a good thing. You need to know how your $ is being earned. Apathy is detrimental to our profession IMO.

In any case, it may be led by "Dr's" but that is to simply bypass the legal requirement that anesthetics in Tx must be under physician direction/supervision. The term "delegation" is hotly contested as far as anesthesia is concerned, but if you're a facility that contracts with Medicare (which 100% do) , irrespective of "delegation", the physician MUST be immediately available to "supervise that delegation". "Supervise that delegation" is a weird term but it’s highly accurate and means what it’s supposed to. It means that with the exception of epidural, all other anesthetic activity by CRNA must have a documented physician (should be anesthesiologist but of course it can be the surgeon if they want to take on the liability of CRNA). Look up Dr Zaafran's letters to Attorney General the last few years.

It really is a problem. Being vague is a problem. These companies model their business on unlimited CRNA numbers with few docs, hoping that nothing happens to the patient and if it does - it will be "oh the patient was too sick", etc etc.

If facility Bylaws dont specify these issues accurately, CRNA led companies have an "in".

Not all sites are the same. For instance, within Essential, one site may have decent MD:CRNA ratio but others may not. In major cities, you wont typically see this problem except here and there.

But the bigger issue is, that philosophically, these companies are shifting how anesthesia is practiced and moving it away from the norm. In terms of safety, MD only care followed by strict medical direction is the best. These companies do not view anesthesia practice that way and they are taking advantage of labor shortage and shifting the standard slowly.

So yes. Can't be a sucker. We need to see and evaluate who we are working for and how it may impact our license and credentials. When we walk into any "job", we may not know all the inner workings so its best to investigate this before showing up.
All employment is voluntary and as an anesthesiologist we have multiple options. Pick the safest and cleanest one for ourselves. Its not always about the money.

 

[MirrorTodd]

so medical direction in San Antonio or ? Extended care team? That’s a pretty low rate - just for your information - I don’t know anyone who works for less than 350 for day time hours.

I was never actually clear on what it actually was. They had another md only site that I primarily worked for, but I have done the other site where I was primarily a preop monkey. As far as I know I wasn’t supervising because the medaxion emr has a button for that. San Antonio has historically had lower pay from what I understand. Not sure why. But like I said, I’m a poor negotiator for a lot of reasons that go all the way back to my childhood of course.

 

[AKMD_1984]

I was never actually clear on what it actually was. They had another md only site that I primarily worked for, but I have done the other site where I was primarily a preop monkey. As far as I know I wasn’t supervising because the medaxion emr has a button for that. San Antonio has historically had lower pay from what I understand. Not sure why. But like I said, I’m a poor negotiator for a lot of reasons that go all the way back to my childhood of course.

Don’t sell yourself short.

The physician shortage is real. I keep telling myself that.

 

[MirrorTodd]

Don’t sell yourself short.

The physician shortage is real. I keep telling myself that.

Ya I appreciate. I gotta remind myself of that too. It’s easy to take advantage of new grads for all the reasons everyone knows.

 

[DirtDocMD]

Bolnick is in on this?? He had “Clinical Partners”, years ago. Ended up selling to EmCare:

EMSC Enters Anesthesiology Outsourcing Market - Redorbit

Emergency Medical Services Corporation (NYSE: EMS) (the "Company") today announced that it has entered into an agreement to acquire the management services entity of Clinical Partners, P.A. (CPPA), a provider of anesthesiology services, as well as an associated billing company.

www.redorbit.com

Always amazed that hospital CEO’s fall for this stuff, and give contracts to “groups” that are little more than a staffing agency.

Oh, well. When your only goal is to try and staff your OR for the lowest cost possible, so you can polish up your corporate CEO resume, and move on to the next job, I guess no one should be surprised….

 

[cchoukal]

Bolnick is in on this?? He had “Clinical Partners”, years ago. Ended up selling to EmCare:

EMSC Enters Anesthesiology Outsourcing Market - Redorbit

Emergency Medical Services Corporation (NYSE: EMS) (the "Company") today announced that it has entered into an agreement to acquire the management services entity of Clinical Partners, P.A. (CPPA), a provider of anesthesiology services, as well as an associated billing company.

www.redorbit.com

Always amazed that hospital CEO’s fall for this stuff, and give contracts to “groups” that are little more than a staffing agency.

Oh, well. When your only goal is to try and staff your OR for the lowest cost possible, so you can polish up your corporate CEO resume, and move on to the next job, I guess no one should be surprised….

did you read the date on that? 2008.

 

[nycitygas]

What hospital did they pick up?
It used to be called emergent health..

 

[DirtDocMD]

did you read the date on that? 2008.

Yes. My point is, the guy sold Clinical Partners in 2008. He’s had a decade and a half to invest the the profits from that sale, and he’s STILL trying to do it, again. Only problem is, nobody’s gonna buy these “mini-AMC’s”, this time. Guess you just keep blowing smoke up hospital CEO’s azzes (Quality! Efficiency! Metrics!) and taking your cut, as long as possible.

 

[cchoukal]

Yes. My point is, the guy sold Clinical Partners in 2008. He’s had a decade and a half to invest the the profits from that sale, and he’s STILL trying to do it, again. Only problem is, nobody’s gonna buy these “mini-AMC’s”, this time. Guess you just keep blowing smoke up hospital CEO’s azzes (Quality! Efficiency! Metrics!) and taking your cut, as long as possible.

Got it. What do people do when their hospital wants "Metrics!" Have you all mastered Epic in such a way to present the kind of data the hospital wants? To pre-empt the management company from making false promise.

 

[MTGas2B]

Slicer-dicer?

Sometime it isn’t enough against the silver tongued snakes.

 

[circleK]

Seriously, who takes an 8-10:1 job, and how do they staff it while that person is giving all of their depositions/trials from said supervision ratio?

 

[AKMD_1984]

8-10 supervision ratio is not Anesthesia.

 

[gunnershow]

Seriously, who takes an 8-10:1 job, and how do they staff it while that person is giving all of their depositions/trials from said supervision ratio?

I've never seen this practice but I imagine it has to be lazy boomers who need to collect checks for their multiple alimonies and car payments. I've seen these types who are loath to ever go in the room and don't care at all about the anesthetic.

 

[nimbus]

8-10 supervision ratio is not Anesthesia.

Correct. That’s nurse anesthesiology😉

 

[rick roller pump]

Probably all of us know at least one doc who would prefer 8:1 (aka doing nothing) to sitting their own room. Embarrassment to the profession.

 

[AKMD_1984]

[

Correct. That’s nurse anesthesiology😉

Yea - It’s something…

 

[DolphinVA]

What hospital did they pick up?
It used to be called emergent health..

I'm not 100% sure, but I think they cover CHI St Luke's Sugar Land, at these 8+:1 ratios. I think they took over when BCM and USAP divided up the Houston area during the CHI takeover of St Lukes around 2017/2018. From their job postings online it looks like they've picked up some other Houston sites also, like HCA Southeast.

 

[IVdoc]

I've spoken with an anesthesiologist in a "collaborative" anesthesia model before. This anesthesiologist who worked there said the CRNAs do the preops, the CRNAs do their own blocks, the CRNAs do OB at the hospital. This anesthesiologist said they don't sign the CRNA charts but they would be responsible if an anesthesia incident occurred. Sounds like a terrible job. Do nothing but get the blame if an OR, OB or block goes bad even when you aren't staffing, never met the patient before. This model probably is active because the administration and anesthesiologists want to make money and someone with an MD/DO will do this job so it continues. It's not how I would want to practice.

 

[caligas]

“Who would take half a mil to do literally nothing??”

I’ve met plenty of docs who would do this, doesn’t surprise me at all.

 

[aneftp]

I've spoken with an anesthesiologist in a "collaborative" anesthesia model before. This anesthesiologist who worked there said the CRNAs do the preops, the CRNAs do their own blocks, the CRNAs do OB at the hospital. This anesthesiologist said they don't sign the CRNA charts but they would be responsible if an anesthesia incident occurred. Sounds like a terrible job. Do nothing but get the blame if an OR, OB or block goes bad even when you aren't staffing, never met the patient before. This model probably is active because the administration and anesthesiologists want to make money and someone with an MD/DO will do this job so it continues. It's not how I would want to practice.

If I knew I was less than 1 year away from calling it quits and offered high dollar to do the work. I would do it. Especially if I could do it remote preop electronically

I wonder how many sites with 1:8/10 have paper preops. That would drive the doc to have early carpal tunnel syndrome.

 

[IVdoc]

So you would be a liability sponge just for the cash? No pride in your chosen profession. The CRNAs would revert to "I'm just a nurse" when the lawsuits pile up and you would be the fall guy/girl doctor. I don't even want to do "supervision" of 3-4:1 but most jobs today are this model and if you want to be an anesthesiologist and feed your family and are limited by geography, you have to take this model. It's a tough reality transition coming from resident to supervision or collaborative attending.

 

[gunnershow]

If I knew I was less than 1 year away from calling it quits and offered high dollar to do the work. I would do it. Especially if I could do it remote preop electronically

I wonder how many sites with 1:8/10 have paper preops. That would drive the doc to have early carpal tunnel syndrome.

You wouldn't feel even a little shame at selling out the profession?

 

[deleted641888]

If I knew I was less than 1 year away from calling it quits and offered high dollar to do the work. I would do it. Especially if I could do it remote preop electronically

I wonder how many sites with 1:8/10 have paper preops. That would drive the doc to have early carpal tunnel syndrome.

So you would be a liability sponge just for the cash? No pride in your chosen profession. The CRNAs would revert to "I'm just a nurse" when the lawsuits pile up and you would be the fall guy/girl doctor. I don't even want to do "supervision" of 3-4:1 but most jobs today are this model and if you want to be an anesthesiologist and feed your family and are limited by geography, you have to take this model. It's a tough reality transition coming from resident to supervision or collaborative attending.

You wouldn't feel even a little shame at selling out the profession?

The answer is "no." There is no shame. I know plenty of anesthesiologists (some on this forum) who have either defended this practice or cosigned this model by staying on board (for $$$ of course). Don't act surprised our colleagues can also be greedy sell-outs.

 

[aneftp]

The answer is "no." There is no shame. I know plenty of anesthesiologists (some on this forum) who have either defended this practice or cosigned this model by staying on board (for $$$ of course). Don't act surprised our colleagues can also be greedy sell-outs.

I’m not defending practice. I don’t think you can Safely (and legally) medically direct more than 1:3 in my opinion higher risk cases.

 

[AKMD_1984]

I've spoken with an anesthesiologist in a "collaborative" anesthesia model before. This anesthesiologist who worked there said the CRNAs do the preops, the CRNAs do their own blocks, the CRNAs do OB at the hospital. This anesthesiologist said they don't sign the CRNA charts but they would be responsible if an anesthesia incident occurred. Sounds like a terrible job. Do nothing but get the blame if an OR, OB or block goes bad even when you aren't staffing, never met the patient before. This model probably is active because the administration and anesthesiologists want to make money and someone with an MD/DO will do this job so it continues. It's not how I would want to practice.

that works, unless the consent form requires the signature of an anesthesiologist.
if you are signing the consent after the fact and without face to face interaction, I do not know how kosher that is.

 

[SRYSPAC]

The answer is "no." There is no shame. I know plenty of anesthesiologists (some on this forum) who have either defended this practice or cosigned this model by staying on board (for $$$ of course). Don't act surprised our colleagues can also be greedy sell-outs.

While it isn't my cup of tea, you cannot blame someone for doing for themselves and their family.

There are plenty of other practice models, so no one is forcing YOU to do that job. Sadly, the "sell out" of the profession happened long ago.

I just wish someone would, with more content creation skills than I possess, use the power of social media and post a satirical, "bragging post" about being an independent nurse anesthesiologist and getting to do procedures and have someone else take the blame when something goes wrong.

"This is the best job in the world, I get to do highly invasive procedures with another medical professional's license on the line when things go wrong, yay! Forget being a doctor, you can pretend to be one and blame them when you f%*$ up!"

 

[gunnershow]

While it isn't my cup of tea, you cannot blame someone for doing for themselves and their family.

There are plenty of other practice models, so no one is forcing YOU to do that job. Sadly, the "sell out" of the profession happened long ago.

I just wish someone with more content creation skills than I possess, used the power of social media and post a satirical, "bragging post" about being an independent nurse anesthesiologist and getting to do procedures and have someone else take the blame when something goes wrong.

"This is the best job in the world, I get to do highly invasive procedures with another medical professional's license on the line when things go wrong, yay! Forget being a doctor, you can pretend to be one and blame them when you f%*$ up!"

You absolutely can blame someone for giving substandard care to patients for disposable income and giving credibility to a model that screws over all the anesthesiologists who actually do care. No anesthesiologist is struggling to take care of their family. Maybe they struggle to take care of their finances, but the poverty card doesn't work here.

 

[gunnershow]

I’m not defending practice. I don’t think you can Safely (and legally) medically direct more than 1:3 in my opinion higher risk cases.

If you can't defend it, then why would you do it?

 

[aneftp]

If you can't defend it, then why would you do it?

I said if I were on my last legs with less than a year to go and can phone it in doing electronic preops from remote location. And they were paying me big bucks like 7 figures where I don’t have to physically move from my computer trading desk. I’d do it

It’s called quiet quitting.

 

[caligas]

I said if I were on my last legs with less than a year to go and can phone it in doing electronic preops from remote location. And they were paying me big bucks like 7 figures where I don’t have to physically move from my computer trading desk. I’d do it

It’s called quiet quitting.

I appreciate the honesty.

Would you be concerned about having early retirement years dampened by a lawsuit?

 

[gunnershow]

I said if I were on my last legs with less than a year to go and can phone it in doing electronic preops from remote location. And they were paying me big bucks like 7 figures where I don’t have to physically move from my computer trading desk. I’d do it

It’s called quiet quitting.

It's called pulling up the rug for every anesthesiologist younger than you. If we don't partake in these models, they don't happen. This is a very boomer attitude... I got mine, I don't care what happens to patients or the generations that follow.

 

[aneftp]

It's called pulling up the rug for every anesthesiologist younger than you. If we don't partake in these models, they don't happen. This is a very boomer attitude... I got mine, I don't care what happens to patients or the generations that follow.

Nah. Just like LeBron James (everyone knows i love basketball). Dude hasn’t played real nba defense since the first trump administration. M

LeBron phones it’s in as well. Does it affect his legacy? Nope. He’s collecting a 100 plus million dollar paycheck in his final 2 years. LeBron got
His as well.

What happens to the quality of basketball being played? When he’s not exerting any effort? Just so he can play with bronny who looked awful vs my sixers last night. And sixers were trying to tank

 

[PainInTheAnes]

I appreciate the honesty.

Would you be concerned about having early retirement years dampened by a lawsuit?

Lawsuits rarely dip into personal assets. It’s almost unheard of unless you’re criminally negligent or personally responsible, like the plastic surgery centers with 25 year olds coding and not getting treatment

 

[caligas]

Lawsuits rarely dip into personal assets. It’s almost unheard of unless you’re criminally negligent or personally responsible, like the plastic surgery centers with 25 year olds coding and not getting treatment

Sure but it’s still a multi year pain in the ass

 

[gunnershow]

Nah. Just like LeBron James (everyone knows i love basketball). Dude hasn’t played real nba defense since the first trump administration. M

LeBron phones it’s in as well. Does it affect his legacy? Nope. He’s collecting a 100 plus million dollar paycheck in his final 2 years. LeBron got
His as well.

What happens to the quality of basketball being played? When he’s not exerting any effort? Just so he can play with bronny who looked awful vs my sixers last night. And sixers were trying to tank

No one watches basketball anymore so there's your answer.

 

[amyl]

There are lots of anesthesiologists that will sell out. Theres lots less integrity than you think. If we would all stick together you could still make nice money doing the right thing…. Perhaps there wouldn’t be enough juice for PE/bankers to take 20-40% but no one would be upset about their exit

 

[aneftp]

No one watches basketball anymore so there's your answer.

Well. People are on their high horses. Other professional entities milk it also and mail it in. They do the bare minimum legally required work.

Just sayin.

 

[centdoc]

It's called pulling up the rug for every anesthesiologist younger than you. If we don't partake in these models, they don't happen. This is a very boomer attitude... I got mine, I don't care what happens to patients or the generations that follow.

This isn’t a boomer attitude… this is what literally everybody would do when they are their way out. Doesn’t matter what the profession is. You will do something like this, too, when you’re on your way out.

 

[PainInTheAnes]

Sure but it’s still a multi year pain in the ass

Not if you’re end of career, which is when aneftp said he’d do that supervision ratio.

I don’t necessarily disagree with the attitude of a late career person in doing that sort of “work”. It’s bad enough in medicine that most doctors would exit or cut back if they could.

I don’t begrudge anyone who views medicine as purely transactional now and tries to game the system. We made it this way with American approach to healthcare and government/private equity intervention.

 

[gunnershow]

This isn’t a boomer attitude… this is what literally everybody would do when they are their way out. Doesn’t matter what the profession is. You will do something like this, too, when you’re on your way out.

No I won't. And this is specific to boomers because plenty of millennials could take these jobs too but the only ones with any interest seems to be boomers who don't care about anything except themselves.

 

[caligas]

Not if you’re end of career, which is when aneftp said he’d do that supervision ratio.

I don’t necessarily disagree with the attitude of a late career person in doing that sort of “work”. It’s bad enough in medicine that most doctors would exit or cut back if they could.

I don’t begrudge anyone who views medicine as purely transactional now and tries to game the system. We made it this way with American approach to healthcare and government/private equity intervention.

Maybe I’m not understanding your point.

It you have a lawsuit from a case on your last day at age 65 wouldn’t you expect the massive aggravation of dealing with it for the next 2-5 years when it’s supposed to be some of the best years of your life?

I was once involved as a defense expert on a case where it was still unresolved 4 years after the anesthesiologist had retired, another one where the anesthesiologist had died with it unresolved

 

[pgg]

Not if you’re end of career, which is when aneftp said he’d do that supervision ratio.

I don’t necessarily disagree with the attitude of a late career person in doing that sort of “work”. It’s bad enough in medicine that most doctors would exit or cut back if they could.

I don’t begrudge anyone who views medicine as purely transactional now and tries to game the system. We made it this way with American approach to healthcare and government/private equity intervention.

During our last round of negotiations, I'm told that an administrator burst out with "you guys are just transactional mercenaries now" and I couldn't be prouder of our board.

We're not stooping to 10:1 pretend-supervision though.

I can and absolutely will fault and look down on doctors who are pretending to be doctors - regardless of what they get paid or what stage of their career they're in.

 

[pgg]

Maybe I’m not understanding your point.

It you have a lawsuit from a case on your last day at age 65 wouldn’t you expect the massive aggravation of dealing with it for the next 2-5 years when it’s supposed to be some of the best years of your life?

I was once involved as a defense expert on a case where it was still unresolved 4 years after the anesthesiologist had retired, another one where the anesthesiologist had died with it unresolved

It might affect people like you and me, but I suspect that the sort of people who'd do this kind of work for a suitably large paycheck are easily able to dissociate their ethical and moral responsibility for giving good care, to a simple numbers-based risk/benefit bit of math.

"Yeah so someone might die, and I might get sued, and rightfully so, but that's what insurance is for, and I'd just let them handle it all, and it'd very likely settle for the policy limit and be over. I wouldn't lose any sleep over it. And maybe the insurance company would drop me afterwards, but hey I'm at the end of my career and I'd just retire then anyway, so no biggie."


See also: "tax evasion is OK because my audit risk is low and at worst I'd just be liable for back taxes and interest/penalties, almost certainly not criminal charges, and besides everyone else is doing it too, and corporations have big loopholes and it's not a big deal" ...

 

[deleted1130227]

During our last round of negotiations, I'm told that an administrator burst out with "you guys are just transactional mercenaries now"

Yes. You MBAs, CPAs, and JDs taught us well.

 

[PainInTheAnes]

Maybe I’m not understanding your point.

It you have a lawsuit from a case on your last day at age 65 wouldn’t you expect the massive aggravation of dealing with it for the next 2-5 years when it’s supposed to be some of the best years of your life?

I was once involved as a defense expert on a case where it was still unresolved 4 years after the anesthesiologist had retired, another one where the anesthesiologist had died with it unresolved

I think you overestimate the actual time commitment of cases like this. In the unlikely event it gets taken to trial, you go and do depositions for a few days. Then maybe to court. It’s not the time sink you think it is unless you’re talking about it affecting future credentialinf. Thats the main hassle in my view, the delay in paperwork previous legal actions cause in the future.

This is having known people who have gone through it. Regardless, lawsuits that are not settled are fairly rare and random occurrences, even with high supervision ratios.

 

[PainInTheAnes]

It might affect people like you and me, but I suspect that the sort of people who'd do this kind of work for a suitably large paycheck are easily able to dissociate their ethical and moral responsibility for giving good care, to a simple numbers-based risk/benefit bit of math.

"Yeah so someone might die, and I might get sued, and rightfully so, but that's what insurance is for, and I'd just let them handle it all, and it'd very likely settle for the policy limit and be over. I wouldn't lose any sleep over it. And maybe the insurance company would drop me afterwards, but hey I'm at the end of my career and I'd just retire then anyway, so no biggie."


See also: "tax evasion is OK because my audit risk is low and at worst I'd just be liable for back taxes and interest/penalties, almost certainly not criminal charges, and besides everyone else is doing it too, and corporations have big loopholes and it's not a big deal" ...

Never said I’d take that job. Just that I understand the people who do.

Let’s not pretend that the larger medical system cares about anything you said. I can see why doctors get burned out and sucked into the malaise of that attitude.

Doctors are human, they respond to incentives and environments, just like everyone else.